LVN Health Care Coordinator Well Med at Hampton - Optum : Job Details

$1500 Sign on Bonus Available for External Candidates

Incentive Bonus 2 times a year

18 days of PTO & Closed on Major Holidays

401K Match

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

The Healthcare Coordinator is responsible for successfully supporting patients with high risk health conditions to navigate the healthcare system. The Healthcare Coordinator assists in developing patient empowerment by acting as an educator, resource, and advocate for patients and their families to ensure a maximum quality of life. The Healthcare Coordinator interacts and collaborates with multidisciplinary care teams, to include physicians, nurses, pharmacists, laboratory technologists, social workers, and other educators to support the transition of care process. The Healthcare Coordinator acts as a resource for clinic staff. The Healthcare Coordinator works in a less structured, self-directed environment and performs all nursing duties within the scope of a LVN/LPN license of the applicable state board of nursing.

Primary Responsibilities:

· Works with the providers and clinic staff to identify patients at high risk through transitions of care. This is to support the market initiative of reducing utilizations, including ER visits, hospital admissions, and hospital readmissions

· Supports longitudinal care of the patient with chronic care conditions by:

o performing assessment of health conditions

o initiating medication reconciliation for PCP to complete

o conducting Motivational Interviewing and Self-Management Goal setting

o providing patient education

· Supports transition of the patient with chronic care conditions from inpatient to outpatient setting, by:

o performing assessment of transitional needs

o initiating medication reconciliation for PCP to complete

o establishing and reviewing contingency plan and 24/7 patient support availability

o providing patient education in a self-management format

o completing 3 in 30 on all high risk members experiencing a discharge

o ensure a 7 calendar day follow up with PCP post discharge

o assisting with post discharge needs such as prescriptions, transportation, Durable Medical Equipment (DME), appointments by creating and following up on social work referrals

o refers to case management for complex case needs, longitudinal needs, and/or disease management

· Coordinate with providers to establish or update plan of care

· Performs accurate and timely documentation in the electronic medical record

· Participates in daily huddles and Patient Care Coordination (PCC) meetings

· Prepares accurate and timely reports, as required, for weekly meetings

· Maintains continued competence in nursing practice and knowledge of current evidence based practices

· May perform clinical tasks within their scope of practice

· Performs all other related duties as assigned

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.